Someone's There

Patients thought to be in a vegetative state were demonstrated to be hearing and thinking.

The rubble doesn’t stir; things are very quiet. But a faint tapping emerges from somewhere below. You shout “Can you hear me?” and more tapping ensues.

You have an idea. “If you can understand me,” you yell, “tap once.” A single tap. “If you’re injured,” you then say, “tap twice.” Two taps. There’s someone there.

The scene conjures the aftermath of a natural disaster like January’s earthquake in Haiti and what is happening now in Chile. But it could also stand as a compelling metaphor for the discovery of a human being struggling to be heard though the rubble of a body that is just too hard to move.

A group of European scientists has employed a high-tech means of, in effect, hearing the tapping of a mind trapped in an unresponsive body. Four patients diagnosed as vegetative and assumed to be unconscious were demonstrated to in fact be aware, despite their inability to move or signal their awareness by moving in any way, even just blinking.

The discovery was the result of the creative use of something called functional magnetic resonance imaging (fMRI), which shows cellular activity across brain regions. What it demonstrated was that the patients were hearing and thinking. And that they could communicate.

The researchers’ discovery utilized the fact that when a person is thinking about active movement, cells in one area of the brain become active; when he visualizes navigating a familiar area, a different area shows cellular activity. The researchers asked the physically unresponsive patients first to imagine swinging a tennis racket and then to imagine moving through the rooms of their houses. The fMRI scan showed activity in the respective, separate areas of the brain with each thought.

That was impressive in its own right. But then the researchers posed a series of factual yes-or-no questions to each patient, like whether he had a parent or sibling with a certain name, and instructed the patient to respond “yes” by imagining playing tennis and “no” by imagining walking through his home. Each patient was instructed to concentrate on the “yes” or “no” thought-activities for a full 30 seconds, well beyond the range of any random brain activity artifact, and they were able to respond accurately.

The results were striking. The answers provided by the four patients, who were part of a tested group of 54, were all correct, demonstrating that consciousness can reside in a body seemingly severed from the world. Before fMRI, such an assertion could have been no more than a statement of faith. Now it is fact. Left for us to speculate is whether some even more sensitive future technology might one day reveal consciousness even in patients whose brains cannot generate signals detectable by current methods.

No one knows what degree of consciousness persists in a body unable to move. But now we know that some degree can persist in some such bodies, belonging to people many would previously have thought of as something less than people.

Some still aren’t convinced they are, in fact, still people. In an editorial in the New England Journal of Medicine, Dr. Allan H. Ropper, a neurologist, warned against, in the New York Times’ words, “equating neural activity [like that seen in the brain scans of the four patients] with [human] identity.” He asserted that “Physicians and society are not ready for ‘I have brain activation, therefore I am.’ That would seriously put Descartes before the horse.” Quite the punster, that Dr. Ropper; but the issue is most serious.

What would we think of someone who looks down at the immobile rubble, hears some faint tapping … and just walks away?

Writing in Great Britain’s The Guardian, University of Glasgow Professor of Law and Ethics Sheila McLean doesn’t treat “brain activation” as casually as Dr. Ropper. On the contrary, she assumes that patients like those who communicated their answers to the European scientists are in fact thinking. Nonetheless, she asks whether “if recovery truly is impossible, is it compassionate to keep people alive in this condition?”

“Frankly,” she asserts, “the only thing worse than being in a vegetative state must be being in one, but being aware.”

Perhaps. But then again, perhaps not. Professor McLean is too quick to discount the value of even such a physically imprisoned life. Is only our movement meaningful?

Men and women in extremis often find themselves facing the question of life’s meaning. Not all of us at the end of our life-journeys will experience epiphanies, but all of us have the potential to be so blessed. And many of us, even if immobile, physically unresponsive and without reasonable hope of recovery, might still engage most important matters – things like forgiveness, repentance, acceptance, commitment, love, God – perhaps the most momentous matters we will ever have considered over the course of our lives. Are such vital encounters worth less than running and jumping? Is ending a life of pure contemplation less objectionable that ending one that includes physical activity?

And, as Professor McLean notes, “the consequence of a diagnosis of permanent vegetative state is that it can be lawful to withdraw assisted nutrition and hydration” – resulting, of course, in the patient’s death.

Back to the aftermath of the natural disaster. What would we think of someone who looks down at the immobile rubble, hears some faint tapping … and just walks away?

Visitor Comments: 19

(19)
donna,
August 26, 2010 8:06 PM

didn't finish

thank g-d both my parents recovered. My father did not remember our conversations but my mother did. this is why it is so important for doctors and visitors to speak positvely when in the presence of such sick people.

(18)
Anonymous,
May 31, 2010 9:28 PM

ask them

While I think it is wrong to withdraw life support from people with detectable brain activity, for those who disagree, I would suggest that since these people can answer yes or no questions, why not ask them if they wish to continue on life support? It should not be up to a third party to make this decision if the patient is aware and able to communicate.

(17)
Daisy,
March 7, 2010 5:55 AM

disturbing

I agree with Sheila Mclean. I think it would be cruel to knowingly keep someone alive in this condition. It would be like an experience of being buried alive and not being able to die. Although Judaism values life, I doubt that such horrible suffering would be considered life and it certainly would not be compatible with Judaism's emphasis on compassion.

(16)
Lea,
March 2, 2010 10:44 PM

For Aura

This article is in the secular media. I read it there before here. It's a challenging issue for sure. With our modern medical advances, it has made it more difficult. I worked in a critical care ward in a hospital with comatose patients. We are always instructed not to talk about them in their presence, because they could understand, even though they didn't seem conscious. We were also told to talk to them as we were caring for them and tell them what we were doing. Life is precious, no matter what the form it is taking at the moment.

(15)
Miriam,
March 2, 2010 2:14 PM

To Aura Slovin

I was astounded and shocked by your story. You should write it up- maybe as an Aish article or possibly even to be published in secular publications. A very impressive, frightening story. Thank you for sharing

(14)
Anonymous,
March 1, 2010 11:50 PM

Experience

To maybe answer one question, I don't think that there is much of a will in those states. Most of the executive functioning is gone and especially initiative. I think that this would be by definition. Let me say that this is also so by experience. So, when trying to get people to answer questions one is drawing on a different part of the brain depending on the injury and what circuits have been interrupted. Now, these states are not all the same. For example, one may be on one's way to the hospital and one can be hearing everything that the ambulance attendants are saying and one is trying to speak but nobody is responding. You can hear such things as, "We are losing him, etc." but you are trying to respond and nobody hears. At the same time you could be praying. You are in a space and it is very comfortable. Then when you cross back it is as if you are waking up. And no, it is not an out of body experience. Then there is the simple awareness where one hears what is being said but the processing is not there. But, if people speak very slowly and if they ask simple questions such as, "Do you love chocolate?" and wait then there is a base understanding. Also, there is appreciation of simple musical melodies. I can keep going but as someone who is writing from experience I can only say one thing: make sure that you have a will.

(13)
,
March 1, 2010 11:17 PM

This article was very painful for me to read - as I experienced this first hand with my father z"l who was in a coma and permenant vegitative state for 2 years. The doctors constatly told us that he was completely unaware and they were just so wrong, as there were instances where I would sing to my father (who's world was music) and although he could not move, tears would stream from his eyes and I felt his absolute consiounce energy although he could not express it physically. We need to remember the value of life for whatever time a person is in this wolrd and its source being from G-D - who are we to take the liberty of deciding when a person's life should be ended as we are taught "yesh hakone olamo beshaa achat" - the effect a person has in this wolrd even within the small last moments is unknown to all of us....

(12)
Claudia Carr,
March 1, 2010 7:43 PM

UK law and ethics

The difficulty with the recent medical advances is that, I believe it throws both the medical law and medical ethics in the UK into question. In the tragic case of Anthony Bland, a young Hillsborough disaster victim who was left in a PVS, the courts agreed that artifical nutrition and hydration be discontinued and his life support machine be turned off, so allowing him to die. If these medical advances do transpire to fulfill their suggested potential then cases similiar to Bland may not, in law be able to follow the same course. In ethics, the answer may well be that cases should not follow the same course as Bland and I cannot agree with Prof. McLean that it be more compassionate to allow patients to die. The patient may have a degree of awareness, but that is not the same as the ability to determine how you, as a patient would wish to be treated (in the medical sense). The concept of a locked in patient where there may be a consciousness but an inability to communicate must be beyond comprehension - there is no easy answer but I believe this and other issues highlight the need in the UK to explore the gulf between UK law, ethics and religion.

(11)
rachel,
March 1, 2010 7:05 PM

kooks?

For Beverly - why do you say kooks? Here is an article proving that they're not kooks. For Anonymous - are you saying that only someone who is conscious deserves to live whereas someone who is aware but not conscious does not? Thats pretty generous of you.

(10)
MIriam,
March 1, 2010 4:36 PM

To Savannah

What about following an individual's desires about whether they would prefer to remove another person from this world; why don't we follow that? How is removing one's own life different than murder; removing someone else's? You have to make a choice; either life is precious or it's not; choose one.

(9)
Miriam,
March 1, 2010 4:33 PM

To Bernie Siegel, M.D.

How much of this "love" will be staying with you? The kind of love that loves so much it won't even try to inspire a loved one to hold on to life?

(8)
Joe Sacks,
March 1, 2010 1:26 PM

Such a good article.... Let us continue to send light and love to those in a coma state, and to assure them any help they need.

(7)
Aura Slovin,
March 1, 2010 4:13 AM

Witnessed with my own eyes....

Many years ago when working in a pediatric Intensive care unit, I had a pt - a 10 yr old boy who while standing on a street corner was struck by an out of control car. He was thrown and resulting injuries included massive brain trauma - he was placed on a ventilator to reduce cerebral edema and 5 days later the Pediatricians informed the parents that he was in a persistant vegetative state and would never recover. Medically he was stable though unresponsive with stable heart and respiratory rates and Blood pressure. After keeping a bedside vigil for more than a week, and with the Intensive Care MD's keeping up the pressure the parents decided to remove him from the ventilator. The night before this was to occur the parents had a 'long talk' with this unconscious child, telling him how much they loved him, how they would miss him but that they could not stand to see him suffer and that the next day at 12 noon they would remove him from his life support. It was a heart rendering scene many staff were in tears along w. the parents who had arranged for their priest to be present on the following day.
I worked in the ICU that night and although he was medically stable, this child expired that night, all his vital signs started going south around 3 hours past 'the talk' and the Doctor's were surprised at this turn of events as he had been supported w. the vent and the medications for the past week in the ICU - so it was unexpected that he should arrest.
.
I wasn't that surprised, it was clear to me - this child heard and understood every word his parents were saying and when they 'gave up the fight for him' in my mind and heart I know he did too.
People do hear in comatose states, the brain is very complex but understand that although they cannot respond verbally or otherwise, there is 'someone home' in there! It gave me an appreciation and respect for life. How precious it is and how one must do all one can to 'keep it going'

(6)
Savannah,
February 28, 2010 9:21 PM

Someones in there

This is an excellent article, but I was wondering did anyone tap and ask the patient if they wanted to stay that way. If this can be a form of communication for some patients maybe they demostrate their desires.

(5)
Beverly Kurtin,
February 28, 2010 9:20 PM

Yipes!

This brought to mind the case n Florida, the Terry Schiavo case. She clearly had no brain left, yet the kooks of the world flocked to her attempting to keep her alive. Due to carotid artery disease, I occasionally stop in my tracks and just STAND there, unable to more. People behind me have no idea, of course, of why I'm just STANDING there like a statue. After several seconds, blood gets to my brain and I usually collapse as though invisible strings that were were suddenly cut. Then comes the real challenge of slurring, "I am okay, please do not call 911." I now wear a MedicAlert bracelet that lets people know of my condition and asking them to NOT call for help. Unfortunately, in many cases, my request is ignored. Then I have to convince the paramedics that I'm okay and show them my bracelet.
BTW, I'm not being stubborn, being transported to a hospital and being admitted to the ER is a costly event, besides, after the event I really AM okay. It is similar to "Shut In Syndrome" that is so often called Vegetative State. I can hear what is going on around me, I simply cannot move or speak. I do understand how traumatic it is for other people to see someone fall for no reason they can see. It is downright scary. But before trying to get an ambulance ask the person if they need one.
I used to have, following a massive stroke, grand mal seizures. I have seen otherwise intelligent people try to stick something in a person's mouth so they "won't swallow their tongue." Try it yourself sometime; you cannot swallow your tongue--it is connected to the bottom of your jaw! Besides, it is not possible to open someone's mouth when they are in the initial state of a seizure. Also, please WAIT for the person to come out of the seizure before assuming that they need to be in the hospital. ASK first. Baruch Hashem, I no longer have seizures, but being in public was scary, never knowing if someone was going to hurt me. Sigh...

(4)
Anonymous,
February 28, 2010 7:04 PM

Yes, there is awareness but it is not consciousness

Being aware and being conscious are two different states. There are many theories about this and we would certainly like to move away from materialism but the central question remains: if one disconnects the machine then what would happen to the body? It would die and without it there is no awareness. These are deep philosophical issues and I don't think that the answer is that because there is awareness then there is life. It has to be understood that we cannot separate awareness from the body. So, once we really understand that issue then we can formulate some answers.

(3)
Bernie Siegel, MD,
February 28, 2010 3:53 PM

people hear you

in coma, asleep and under anesthesia we hear. i know from my experience so always talk to people. and when you have someone in a vegetative state let them know it is okay to go if they want to that their love will stay with you. you do not have to pull the feeding tube. they will turn off the switch and die peacefully surrounded by loved ones. i know from my experience.

(2)
raye,
February 28, 2010 2:39 PM

I wish I had known that someone was still there.

My sister was lying in a hospice bed being fed morphine intraveneously for she was dyng of cancer. I was with her the last week. While there was no communication, I kept singing songs that we sang every summer
during our vaudeville days as part of a "kiddie troupe" on the Borsht Belt in the Catskill Mts of New York in the early 1930s
I was stunned when I heard her say "I'm sorry, forgive me."
I was so totally unprepared, for this apology I could not answer. It isn't necessary to mention how she had hurt me in the past.I wish I had known that somebody was still there for those were the last words she had spoken.

(1)
Bracha Goetz,
February 28, 2010 1:31 PM

Thank you for this very important article.

And we must not walk away from all the victims of abuse in our midst - who are calling out to us in pain.

I'm told that it's a mitzvah to become intoxicated on Purim. This puzzles me, because to my understanding, it is not considered a good thing to become intoxicated, period.

One of the characteristics of the at-risk youth is their use of drugs, including alcohol. In my experience, getting drunk doesn't reveal secrets. It makes people act stupid and irresponsible, doing things they would never do if they were sober. Also, I know a lot about the horrible health effects of abusing alcohol, because I work at a research center that focuses on addiction and substance abuse.

Also, I am an alcoholic, which means that if I drink, very bad things happen. I have not had a drink in 22 years, and I have no intention of starting now. Surely there must be instances where a person is excused from the obligation to drink. I don't see how Judaism could ever promote the idea of getting drunk. It just doesn't seem right.

The Aish Rabbi Replies:

Putting aside for a moment all the spiritual and philosophical reasons for getting drunk on Purim, this remains an issue of common sense. Of course, teenagers should be warned of the dangers of acute alcohol ingestion. Of course, nobody should drink and drive. Of course, nobody should become so drunk to the point of negligence in performing mitzvot. And of course, a recovering alcoholic should not partake of alcohol on Purim.

Indeed, the Code of Jewish Law explicitly says that if one suspects the drinking may affect him negatively, then he should NOT drink.

Getting drunk on Purim is actually one of the most difficult mitzvot to do correctly. A person should only drink if it will lead to positive spiritual results - e.g. under the loosening affect of the alcohol, greater awareness will surface of the love for God and Torah found deep in the heart. (Perhaps if we were on a higher spiritual level, we wouldn't need to get drunk!)

Yet the Talmud still speaks of an obligation on Purim of "not knowing the difference between Blessed is Mordechai and Cursed is Haman." How then should a person who doesn't drink get the point of “not knowing”? Simple - just go to sleep! (Rama - OC 695:2)

All this applies to individuals. But the question remains - does drinking on Purim adversely affect the collective social health of the Jewish community?

The aversion to alcoholism is engrained into Jewish consciousness from a number of Biblical and Talmudic sources. There are the rebuking words of prophets - Isaiah 28:1, Hosea 3:1 with Rashi, and Amos 6:6, and the Zohar says that "The wicked stray after wine" (Midrash Ne'alam Parshat Vayera).

It is well known that the rate of alcoholism among Jews has historically been very low. Numerous medical, psychological and sociological studies have confirmed this. The connection between Judaism and sobriety is so evident, that the following conversation is reported by Lawrence Kelemen in "Permission to Receive":

When Dr. Mark Keller, editor of the Quarterly Journal of Studies on Alcohol, commented that "practically all Jews do drink, and yet all the world knows that Jews hardly ever become alcoholics," his colleague, Dr. Howard Haggard, director of Yale's Laboratory of Applied Physiology, jokingly proposed converting alcoholics to the Jewish religion in order to immerse them in a culture with healthy attitudes toward drinking!

Perhaps we could suggest that it is precisely because of the use of alcohol in traditional ceremonies (Kiddush, Bris, Purim, etc.), that Jews experience such low rates of alcoholism. This ceremonial usage may actually act like an inoculation - i.e. injecting a safe amount that keeps the disease away.

Of course, as we said earlier, all this needs to be monitored with good common sense. Yet in my personal experience - having been in the company of Torah scholars who were totally drunk on Purim - they acted with extreme gentleness and joy. Amid the Jewish songs and beautiful words of Torah, every year the event is, for me, very special.

Adar 12 marks the dedication of Herod's renovations on the second Holy Temple in Jerusalem in 11 BCE. Herod was king of Judea in the first century BCE who constructed grand projects like the fortresses at Masada and Herodium, the city of Caesarea, and fortifications around the old city of Jerusalem. The most ambitious of Herod's projects was the re-building of the Temple, which was in disrepair after standing over 300 years. Herod's renovations included a huge man-made platform that remains today the largest man-made platform in the world. It took 10,000 men 10 years just to build the retaining walls around the Temple Mount; the Western Wall that we know today is part of that retaining wall. The Temple itself was a phenomenal site, covered in gold and marble. As the Talmud says, "He who has not seen Herod's building, has never in his life seen a truly grand building."

Some people gauge the value of themselves by what they own. But in reality, the entire concept of ownership of possessions is based on an illusion. When you obtain a material object, it does not become part of you. Ownership is merely your right to use specific objects whenever you wish.

How unfortunate is the person who has an ambition to cleave to something impossible to cleave to! Such a person will not obtain what he desires and will experience suffering.

Fortunate is the person whose ambition it is to acquire personal growth that is independent of external factors. Such a person will lead a happy and rewarding life.

With exercising patience you could have saved yourself 400 zuzim (Berachos 20a).

This Talmudic proverb arose from a case where someone was fined 400 zuzim because he acted in undue haste and insulted some one.

I was once pulling into a parking lot. Since I was a bit late for an important appointment, I was terribly annoyed that the lead car in the procession was creeping at a snail's pace. The driver immediately in front of me was showing his impatience by sounding his horn. In my aggravation, I wanted to join him, but I saw no real purpose in adding to the cacophony.

When the lead driver finally pulled into a parking space, I saw a wheelchair symbol on his rear license plate. He was handicapped and was obviously in need of the nearest parking space. I felt bad that I had harbored such hostile feelings about him, but was gratified that I had not sounded my horn, because then I would really have felt guilty for my lack of consideration.

This incident has helped me to delay my reactions to other frustrating situations until I have more time to evaluate all the circumstances. My motives do not stem from lofty principles, but from my desire to avoid having to feel guilt and remorse for having been foolish or inconsiderate.

Today I shall...

try to withhold impulsive reaction, bearing in mind that a hasty act performed without full knowledge of all the circumstances may cause me much distress.

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